SHAME OF THE CITY – THE SEQUELSLUM HOUSING: L.A.’S HIDDEN HEALTH CRISIS

Enhancing Community Health by Improving Housing and Health Practices, Aligning Government Priorities and Increasing the Power of Tenants

The Healthy Neighborhoods Same Neighbors Collaborative is Strategic Actions for a Just Economy; Los Angeles Community Action Network; St. John’s Well Child

and Family Center, and Esperanza Community Housing Corporation

Executive Summary

There is a fundamental crisis of health and human rights in Los Angeles, particularly in Downtown and South Los Angeles. Contributing to the crisis are substandard and slum housing conditions that permeate these communities causing direct and serious health consequences for residents who are primarily tenants and children. The negative health outcomes which result from living in slum housing conditions represent a substantial public health hazard.

This report documents the two-year Slumlord Criminalization and Health Impact Project, a project of the Healthy Neighborhoods, Same Neighbors Collaborative. This unique coalition includes health care providers, community health workers/promotoras, tenant and community organizers, and affordable housing and human rights advocates.

The health effects of slum housing are vast and profound, ranging from the development and aggravation of asthma and allergy conditions to chronic lead poisoning; from chronic sinusitis to chronic skin diseases; from insect and rodent bites as well as diarrheal illnesses to anxiety and other mental health conditions. Many tenants suffer not only from structural conditions of their home but also from constant fear of eviction, displacement and banishment, increasing their susceptibility to and/or exacerbating mental illness.

Intensifying the problem is the public system in Los Angeles to monitor and enforce housing codes, which is ineffective, inconsistent and does not result in consequences that change the behavior of professional, criminal landlords. The system has been remarkably ineffective, and the responsible agencies rarely conduct joint evaluations, strategic planning, or shared interventions to increase alignment of resources and effectiveness.

In response to the interrelated causes of negative health outcomes resulting from living in slum housing, and building on twelve years of previous work, the Healthy Neighborhoods, Same Neighbors Collaborative launched the Slumlord Criminalization and Health Impact Project. The project deployed a set of integrated and aligned tactics intended to produce:• measurable improvement in the individual and environmental health conditions of children and

families; and • a change in the views and behavior of public agencies, public officials, and the media towards slum

landlords and tenants who live in slum buildings.

Methodology, Findings, and Outcomes

One of the first steps in this project was to identify children and families facing the most serious health conditions and most egregious slum housing conditions. The health consequences of slum housing conditions are unacceptable and much of the impact falls upon children.

For example, in a survey of 140 tenants, we found that: 45% of tenants’ units had mold; 75% had cockroaches; 40% had rats or mice, compared to 7% for renters nationwide; 34% had bedbugs; 44% reported lack of running water for episodes lasting more than 6 hours; 39% reported leaks from pipes and plumbing within their homes, compared to 11% of renters nationwide; and 47% reported having areas of broken plaster or peeling paint that were at least as large as a piece of paper, compared to just 3% of renters nationwide.

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When we asked the same group of tenants about their health, we found significant rates of slum housing related illnesses including: 49% suffered chronic allergic symptoms; 42% suffered chronic skin rashes; 25% reported suffering asthma and one out of every seven asthmatics reported wheezing every night in the past 2 weeks; 15% reported family members who have suffered lead toxicity; 40% of tenants surveyed reported feeling down, depressed or hopeless; and nearly half of tenants reported having either fair or poor health.

In response, our collaborative constructed a systematic approach to slum housing investigation and litigation to match the challenge presented by large-scale professional slumlords. Our methodology included the following integrated strategies: 1) research; 2) community organizing; 3) direct medical care, using a social medicine model; 4) health promotion; 5) legal interventions; 6) media; and 7) broad civic engagement.

The project ultimately involved:•3 multi-property slumlords•195 buildings•over 3,150 units of extreme slum housing inhabited by low-income families, people with disabilities,

children, seniors, and others with few or no other choices in Los Angeles’ housing market.

There were four core impacts as a result of the project:

1. Improved individual health outcomes: The health consequences of slum housing conditions are shocking. However, among those project participants we surveyed, the vast majority of residents reported an improvement in health status due to the collaborative interventions of this project. One hundred percent of respondents engaging with all 4 collaborative agencies reported improvements in their health. These health improvements were related in large part to improvements in housing conditions among those we surveyed, a fact that further establishes that housing itself is a critical determinant of health.

2. Improved environmental health conditions in targeted buildings: The large majority of residents reported an improvement in housing conditions due to the collaborative interventions of this project. Additionally, project collaborators documented improvements in environmental health conditions in the majority of buildings included in the pilot project. Of the 3,150 families in the pilot project properties, more than 90% experienced major improvements in living conditions.

3. Improvements in housing and health practices and government alignment: One significant outcome was securing a commitment from the City Attorney’s office to dedicate resources to large, criminal slumlord activity and utilize innovative criminal charges including the possibility of using child endangerment statutes and case law to prosecute intransigent slumlords. The combined result of these pilot cases can serve as an example of the consequences for landlords who engage in longstanding profit-making through disinvestment and criminal behavior and, hopefully, influence the behavior of all landlords in the City. Additionally, the collaborative secured a commitment from the LA County Department of Public Health to assign public health nurses to work directly with physicians, clinic staff and community health promoters to help address the particular health conditions of children and families living in slum housing units.

4. Increased power of tenants to change policy and practices: More than 2,500 tenants were engaged in at least one aspect of the project. Among those tenants, there were more than 250 core tenants who participated in health education and tenant rights sessions, filed complaints to government agencies and/or were plaintiffs in lawsuits, conducted outreach among their neighbors, organized building-wide

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meetings, collected documentation for and participated in legal efforts, gave public testimony, planned and engaged in direct action, and provided crucial information and leadership to move the goals of this project forward. Grassroots leadership was both a necessary and highly effective component of this project, as well as our ongoing health and human rights efforts.

Conclusions and Next Steps

There are three key areas in which the Slumlord Criminalization and Health Impacts project can help inform future policy and practice:

1. Health and Human Rights Framework and Practice The Healthy Neighborhoods, Same Neighbors Collaborative, as well as dozens of our community partners and hundreds of residents, are committed to creating programs and projects that promote interdependent, interrelated human rights approaches. We believe this project, as well as several other community-based efforts, provide a model for government officials to follow. Public resources simply must build upon, support and supplement effective community-based strategies.

2. South Los Angeles Integrated Health Care SystemAs Los Angeles County moves forward in developing and implementing the South LA Integrated Health Care System, it must include coordinated interventions that address immediate health needs as well as the multiple social determinants of health, including housing conditions. We believe that our collaborative is uniquely qualified to inform this process.

3. Community Leadership and PowerEngagement of those most impacted by human rights violations is a necessary component of implementing the human rights framework. Additionally, developing community leadership is essential to building the power needed to influence systems change. This project and similar efforts continue to demonstrate both the need for and effectiveness of low-income residents who are deeply engaged in creating and implementing true sustainable solutions to health and housing needs.

Through the work of this collaborative, we have transformed patients into active change-makers, expanded the role of tenant leaders and community health promoters into human rights defenders, broken down barriers between traditional housing and health work, and have built the foundations for a broad base of residents working together in solidarity across race, geography and issue area.

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Quotes of residents involved in the Slumlord Criminalization and Health Impact Project

“When we turn the hot water on it burns our skin. We’re afraid that the top floor will fall on us from the humidity. The managers are not available during business hours.”

“The closet and bathroom doors don’t work. While I was still pregnant, I was yelled at by the landlord and felt so bad I had to go to the hospital.”

INTRODUCTION

There is a fundamental crisis of health and human rights in Los Angeles, particularly in Downtown and South Los Angeles. These communities have a population of mostly working class Latino immigrants and African American families who have limited access to health care services and safe and healthy, affordable housing. Contributing to the crisis are substandard and slum housing conditions that permeate these communities causing direct and serious health consequences for residents who are primarily mostly tenants and children.

The negative health outcomes which result from living in slum housing conditions represent a substantial public health hazard.

Despite substantial evidence and experience that links poor health and slum housing, the public agencies responsible for housing conditions and health outcomes have yet to work together to remove the hazard. Contrary to the evidence, many public officials continue to regard slumlords as legitimate business people who suffer at the hands of ‘problem tenants,’ rather than lawbreakers who repeatedly violate the public trust and the human rights of hard-working families.

But public agencies are not alone. Civic organizations and service providers who share a vision of improved health and housing often miss opportunities to create the collaboration and alignment which is necessary to produce effective solutions. This report is the result of such a collaboration and push for alignment between organizers, community health clinics, health promoters, doctors, and researchers in Los Angeles who have adopted a human rights approach to health and housing. This report documents the team’s assumptions, methodology, findings and outcomes. It includes evidence of the direct public health consequences of slum housing and strategies for collaborative interventions that produce specific health improvements.

About the AuthorsThis report is the product of a collaborative partnership among the following community-based organizations, each of which possesses a unique working perspective on the slum housing health crisis in Los Angeles:

• St. John’s Well Child and Family Center (St. John’s) A network of federally qualified health centers and school-based clinics providing medical, dental, mental health and social services to more than 100,000 annual patient visits. Headquartered in South Los Angeles with eleven sites in the County, St. John’s provides a medical home to over 35,000 low- income children and families.

• LA Community Action Network (LA CAN) A grassroots organization focused primarily on human and civil rights, housing, and leadership development. Based in the downtown community, LA CAN organizes Los Angeles’ poorest residents to prevent displacement, increase access to safe and affordable housing, and build a healthy and equitable Downtown and South Los Angeles.

• Strategic Actions for a Just Economy (SAJE) An economic justice and tenant rights organization that works with local residents to combat slum housing, organizes residents to engage in the City and Community Redevelopment Agency’s land use planning process in order to increase the amount of affordable and safe housing in the area, works to halt illegal evictions and the ongoing displacement of Los Angeles’ working families.

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• Esperanza Community Housing Corporation (Esperanza) In addition to developing 265 units of quality affordable housing for very low-income families, Esperanza has also developed a model community health promoter program that has trained over 330 bilingual community members as Promotores de Salud, most of whom are from Downtown and South Los Angeles. Among this cadre of community health leaders, Esperanza’s Healthy Homes Team focuses on the environmental impact of housing conditions on the health of children and families.

This unique coalition includes health care providers, community health workers/promotoras, tenant and community organizers, and affordable housing and human rights advocates. Driven by the needs of common constituents and a shared commitment to health and human rights, our organizations have a long history of working together to build groundbreaking community-based human rights and public health initiatives.

An Evolving 14-Year CollaborationThe origins of the collaborative are in 1996, when two of the organizations began coordinating work around lead poisoning prevention, health services and treatment for children with elevated blood lead levels, and in-home community health promotion visits. As the depth of the problem became known, it became increasingly clear that community and tenant organizing, as well as public health strategies, needed to be integrated with the original efforts. Between 1996 and 2003, new partners joined the coalition, our core focus and methods of work were clearly defined, and several projects were implemented.

From 2004 to 2006, the Better Neighborhoods, Same Neighbors Initiative identified critical connections between growing health disorders, such as childhood asthma and lead poisoning, and slum housing in the Figueroa Corridor, from Downtown through South Los Angeles.1 That work produced a seminal report, The Shame of the City, which alerted Los Angeles about the critical threat of slum housing to the health of LA’s children and families and outlined an evidence-based etiology of slum housing disease. In 2008, the Taming the Perfect Storm report produced by this collaborative documented our work to prevent displacement and homelessness. This report also highlighted a powerful shift in our framework toward utilizing a health and human rights framework to understand and address the latest combined assaults on our community’s health in connection to the growing numbers of displaced residents in South Los Angeles.

The collective organizing, advocacy and service strategies which were documented in these ground-breaking reports expanded to a broader coalition effort in 2009 to host the First Annual South Los Angeles Health and Human Rights conference and develop the South Los Angeles Declaration of Health and Human Rights. This health and human rights initiative has involved thousands of South Los Angeles residents, advocates, service providers and civic leaders. This report will document the two-year Slumlord Criminalization and Health Impact Project, a crucial piece of the ongoing health and human rights initiative.

1 Lowe, A. and Haas, G. eds., The Shame of the City: Slum Housing and the Critical Threat to the Health of L.A. Children and Families. 2007, Strategic Actions for a Just Economy: Los Angeles.

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FIGURE 1: Long Term Impacts frrom Slum Housing

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Quotes of residents involved in the Slumlord Criminalization and Health Impact Project

“The baby gets a rash because of the bed bugs. The coldness also affects the baby’s bones.”

“I have a high level of stress. Our unit is full of lead dust. I have a new born and am really concerned for her health.”

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SLUMLORD CRIMINALIZATION AND HEALTH IMPACT PROJECT

OVERVIEW

A. An Evidence-Based Etiology of Slum Housing Disease

The link between health and substandard/slum housing has been well established in public health and medicine (See Appendix A). Respected scientific authorities, including the Institute of Medicine and the World Health Organization, indicate that exposure to mold, dust mites, cockroaches, bedbugs, chipping and peeling lead-based paint, damp conditions, poor sanitation and structural security are among several slum-housing related conditions that result in harm to the health of children and families. For instance, a recent article in the American Journal of Public Health, Home is Where the Harm Is: Inadequate Housing as a Public Health Crisis, discusses some of the “ill effects on family health” that substandard housing actually inflicts upon its inhabitants due to the dangers it harbors. This literature supports what the staff and members of the collaborative partners see every day.

None of this literature, as important as it is to advancing the understanding of housing as a determinant of health, has actually developed an evidence-based etiology of slum housing disease -- in other words, precisely what diseases are caused and exacerbated by slum housing conditions. One of the key strengths and successes of our collaborative approach has been to identify and document the broad array of slum-housing-induced diseases and conditions which thousands of Downtown and South Los Angeles residents suffer from as a direct result of the housing conditions in which they live.

As illustrated in Figure 1 below2 , the health effects of slum housing are vast and profound, ranging from the development and exacerbation of asthma and allergy conditions to chronic lead poisoning; from chronic sinusitis to chronic skin diseases; from insect and rodent bites as well as diarrheal illnesses to anxiety and other mental health conditions. Many tenants suffer not only from structural conditions of their home but also from constant fear of eviction, displacement and banishment, increasing their susceptibility to and/or exacerbating mental illness. Everyday, health care providers pull cockroaches out of patients’ ears; promotoras educate parents about ways to reduce their children’s asthma attacks and deal with other health consequences of slum housing; organizers help anxious and fearful tenants defend their tenant rights and demand changes to slum housing conditions. It is this combination of clinical and home-based health interventions, with innovative legal strategies, that has led to improved overall health outcomes.

B. Professional Slumlords Fall Through the Cracks of an Award-Winning System

In Los Angeles, the public system to monitor and enforce housing codes is ineffective and inconsistent, and does not result in consequences that change the behavior of professional, criminal landlords.

The main system for addressing slum housing conditions in Los Angeles involves the following: • building inspectors and inspections from the City’s Housing Department and the County’s Public

Health Department;• referrals of non-compliant cases to the City’s Slum Housing Task Force;• assignment of a City Attorney to file complaints against selected non-compliant landlords; and, • the Rent Escrow Account Program (REAP) which places rents of non-compliant buildings into a

2 Lowe, A. and Haas, G. eds., IDIB.

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rust account and typically reduces the rent of tenants until slum conditions are resolved. On the face of it, this system should be adequate. In fact, the City’s “Systematic Code Enforcement Program” has won the highest level of awards from the federal government. However, in reality, the system has been remarkably ineffective, and the responsible agencies rarely conduct joint evaluations, strategic planning, or shared interventions to increase alignment of resources and effectiveness.

A Gap in Inspection MethodsA striking illustration of the situation occurred in January 2009 when only five months after passing a city inspection, a four-unit building in Koreatown owned by a notorious slumlord, Frank McHugh, collapsed while tenants slept inside. In this case, the City’s inspectors failed to identify the structural dangers lurking in the building. As a result, there were no citations made against McHugh and no orders to comply with housing codes were issued.

Upon further investigation it was found that the public agencies have no system for inspectors to evaluate structural flaws in a building that are the result of years of neglect, nor do they have methods to detect whether plumbing and electrical problems in individual units are the result of entire failed systems that need to be replaced. This example demonstrates how unhealthy building conditions can escalate to the level of catastrophe. Environmental health interventions by public agencies, such as lead remediation, often focus on an individual unit despite the likelihood that the entire building needs remediation.

Blaming the VictimsAnother impediment against curing housing-induced health problems are attitudes held by City personnel and landlords. Slumlords have been historically treated by building inspectors and other public agency staff as “business people” with a problem.

In contrast, slumlords (and often public officials and the media) promote the concept that slum building conditions are the fault of “bad” tenants. These characterizations are most common when the landlord wants to redevelop his or her building for rental or sale to higher income residents.

According to the Los Angeles Times, Donald Sterling, a notorious slumlord who owns 5,000 rental units in Los Angeles County, told members of his staff that he did not like to rent to Latinos or African Americans because “Mexicans just sit around and smoke and drink all day,” and “blacks in this building, they smell, they’re not clean.”

These biased perceptions make the demolition of a slum building and the wholesale displacement of tenants seem like expedient solutions to unhealthy housing conditions, rather than making building repairs and correcting years of “deferred” maintenance.

Our research has shown that landlords who have long-term, large holdings of slum buildings make money by collecting rent without investing in necessary repairs. This is actually their business plan. It is intentional, profitable, and illegal3.

3 Lowe, A. and Haas, G. eds., IBID.

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C. The Slumlord Criminalization and Health Impact Project

The goals of the Slumlord Criminalization and Health Impact Project are to deploy a set of integrated and aligned tactics that produce:• measurable improvement in the individual and environmental health conditions of children and

families; and • a change in the views and behaviors of public agencies, public officials, and the media towards slum

landlords and tenants who live in slum buildings.

Our strategy included a combination of:• community organizing;• direct health services;• medical care coordination and case management; • environmental health and home assessment;• health education;• litigation;• advocacy; and • civic engagement.

The two-year objectives for 2008-2009 were: • To improve health outcomes of tenants living in substandard or slum housing;• To eliminate slum housing conditions for tenants of buildings involved in the project;• To document medical evidence showing the correlation between health conditions and housing

conditions, as well as the impact of the coordinated interventions of health services, health promotion, and community organizing;

• To pilot a systematic approach to targeting slumlords who own multiple buildings in Downtown and South Los Angeles that are directly and negatively impacting the health of the children and families who live there;

• To improve alignment and coordination among public agencies resulting in enhanced inspections, harsher consequences for code violators and improved living conditions; and

• To document the collective interventions and results as a means of informing public policy and practices of health care providers, community organizers, public and private attorneys, and other crucial stakeholders responsible for improving community health and housing outcomes.

METHODOLOGY and FINDINGS

A. Survey tenants who live in slum buildings

One of the first steps in this project was to identify children and families facing the most serious health conditions and most egregious slum housing conditions. When we assessed a sample of tenants who received services from our collaborative, the extent of the housing-related health crisis in Downtown and South Los Angeles was startling in comparison to national averages.

We adapted validated questions from the American Housing Survey to assess housing conditions of over 140 households.

Survey ResultsWhen asked about conditions inside their homes, we found that:• 45% of tenants’ units had mold;

• 75% had cockroaches; • 40% had rats or mice, compared to 7% for renters nationwide;• 34% had bedbugs; • 44% and 53% reported being uncomfortably cold or hot, respectively, for more than 24 hours; • 44% reported lack of running water for episodes lasting more than 6 hours;• 15% reported living with exposed electrical wiring (an obvious hazard for burns and electrocution)

compared to only 1% of renters nationwide who experience the same problem;• 30% reported experiencing water leaking into their homes from outside, compared to 9% of renters

nationwide;• 39% reported leaks from pipes and plumbing within their homes, compared to 11% of renters

nationwide;• 45% reported holes or cracks in their walls larger than a dime, compared to only 7% of renters

nationwide; and• 47% reported having areas of broken plaster or peeling paint that were at least as large as a piece of

paper, compared to just 3% of renters nationwide.

The American Housing Survey asserts that these kinds of conditions are substandard and hazardous to the health of tenants, consistent with our findings. As comparisons with national averages illustrate, low-income residents in Downtown and South Los Angeles experience alarming levels of unhealthy and hazardous living conditions inside their homes.

A Violation of Human RightsThe aforementioned conditions are also clear violations of strict standards established by the Universal Declaration of Human Rights. Article 25.1 of the Universal Declaration of Human Rights affirms: “Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

Housing-Induced Health ConditionsWhen we asked the same group of tenants about their health, we found that:• Nearly half (49%) suffered chronic allergic symptoms such as watery or itchy eyes or nose; • Over 4 in 10 (42%) residents suffered chronic skin rashes;• Four in every 10 tenants surveyed reported insect bites;• One-quarter (25.2%) reported suffering asthma and the majority of those with asthma had uncontrolled

asthma, with at least wheezing once in the past two weeks;• One out of every seven asthmatics reported wheezing every night in the past 2 weeks;• 15% reported family members who have suffered lead toxicity (defined as levels greater than 5mg/dl).• 16% reported that they had fallen within their buildings; • Nearly 1 in 3 tenants suffered gastrointestinal symptoms or conditions: stomach aches, gastroenteritis, or

poor appetites among children and other family members; • 40% of tenants surveyed reported feeling down, depressed or hopeless; • 1 in 3 (33%) reported experiencing chronic anxiety or fear specifically related to their housing conditions;

and• Nearly half of tenants we surveyed reported having either fair or poor health.

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FIGURE 2:

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FIGURE 3:

Health Conditions Resulting from Slum Housing

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The health consequences of slum housing conditions are unacceptable and much of the impact falls upon children (see Figures 2 and 3).

Health Conditions Resulting from Slum Housing

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While suffering from a single health or housing condition is unacceptable, Figures 4 and 5 (below) illustrate that the majority of respondents are suffering from three or more housing or health conditions.

FIGURE 4:

FIGURE 5:

Number of Housing Conditions in the Household

Number of Health Conditions in the Household

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B. A Systematic Approach to Slum Housing and Health

Among those who reported slum housing conditions in our survey, only 15% said their landlords responded with repairs.

In response, our collaborative constructed a systematic approach to slum housing investigation and litigation to match the challenge presented by large-scale professional slumlords.

The project ultimately involved:

•3 multi-property slumlords•195 buildings•over 3,150 units of extreme slum housing inhabited by low-income families, people with disabilities,

children, seniors, and others with few or no other choices in Los Angeles’ housing market.

Our methodology included:

Research strategy•Identifying owners of multiple slum buildings, particularly those who had been involved in the City’s

Rent Escrow Account Program (REAP).

Organizing Strategy•Targeting specific large slum owners•Organizing tenants in buildings that qualified for REAP but were not yet in the program•Building relationships between tenants within and across buildings owned by the same owners

Medical Strategy• Developed a standard of clinical care that incorporated questions and education about the impact of

housing on one’s health•Documenting patients’ health conditions caused or exacerbated by slumlord negligence •Physicians and public health advocates employed the etiology of slum housing disease to provide

crucial evidence in support of legal interventions that documented the connection between environmental health conditions and individual health outcomes

Promotora/Health Promoter Strategy•Received referrals from collaborative partners because of either medical symptoms (using the Etiology

of Slum Housing Disease) or slum housing conditions •Conducted home visits to assess housing conditions and to identify building triggers of ill health

(inappropriate humidity, chipping and peeling paint, vermin infestation, etc.) •Collected environmental samples and provided education on nutrition, cleaning methods and

integrated pest management •Linked families from our database to a medical home and/or to tenant a rights organizer•Conducted door-to-door assessments in each unit when referrals from collaborative partners led to a

sub-standard building

Legal Strategy•tenants obtained legal representation from public interest attorneys for civil violations•City Attorney filed criminal charges against the three multi-property owning landlords

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Media Strategy•Framing slum housing business practices as explicitly criminal •Employing that frame in the media to increase the visibility of slumlord practices and their impact on

community health to the general public

Civic Engagement Strategy•The results of all of the above community engagement and research were presented to public interest

lawyers, elected officials, and staff of public agencies including the LA City Attorney’s office•Collaborative partners engaged tenants in public hearings, public actions, and media •campaigns to clarify their status as victims (rather than perpetrators of slum conditions), as people

whose rights were being violated, and whose landlords acted with criminal intent to maximize profits and minimize investment

All interventions were coordinated to maximize impact. To manage the complex systemic approach, tenant organizers, promotoras/health promoters, doctors and other health professionals met monthly to evaluate our efforts, plan and strategize our next steps, analyze health data being collected, share best practices among sub-groups, and troubleshoot.

Our experience shows that the strategic and coordinated combination of community organizing, health promotion, direct health services, and legal interventions is one of the core elements of our success.

IMPACTS AND OUTCOMES

The four core impacts of the project are: 1. Improved individual health outcomes;2. Improved environmental health conditions in targeted buildings;3. Improvements in housing and health practices and government alignment; and,4. Increased power of tenants to change policy and practices.

A. Improved Individual Health Outcomes

Our collaborative aimed to reduce the public health hazard caused by slumlords among the residents of South Los Angeles. In order to determine the extent of our impact, we assessed a cohort of 140 residents who participated in the project during the second year.

The vast majority of residents with health conditions and significant housing-related symptoms reported health improvements after participating in collaborative activities. For example, 4 out of 5 residents with anxiety related specifically to substandard housing conditions reported health improvements. While the majority of residents with multiple health problems reported significant improvements in health, the impact of the collaborative was greatest (93%) among those with more than 2-5 health conditions. Residents suffer multiple housing-related health problems at the same time (upwards of 16 in some cases), underscoring the severity of the public health hazard of slum housing.

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FIGURE 6:

COLLABORATIVE INTERVENTIONS

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Figure 6 illustrates the types of collaborative interventions and participant activities utilized in this project. This figure reflects the extensive and innovative use of promotoras, medical visits, and organizing interventions.

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In fact, 100% of respondents engaging with all 4 collaborative agencies reported improvements in their health.

These health improvements were related in large part to improvements in housing conditions among those we surveyed, a fact that further establishes that housing itself is a critical determinant of health.

Figure 8 shows that the large majority of residents reported an improvement in housing conditions due to the collaborative interventions of this project.

As noted in previous sections, the health consequences of slum housing conditions are shocking. However, among those participants we surveyed, the vast majority of residents reported an improvement in health status due to the collaborative interventions of this project (see Figure 7, below).

FIGURE 7:

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HEALTH CHANGE SINCE COMING INTO CONTACT WITH ORGANIZATIONS

FIGURE 8:

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HOUSING CHANGE SINCE COMING INTO CONTACT WITH ORGANIZATIONS

The vast majority of residents with health conditions and significant housing-related symptoms reported health improvements after participating in collaborative activities. For example, 4 out of 5 residents with anxiety related specifically to substandard housing conditions reported health improvements. While the majority of residents with multiple health problems reported significant improvements in health, the impact of the collaborative was greatest (93%) among those with more than 2-5 health conditions. Residents suffer multiple housing-related health problems at the same time (upwards of 16 in some cases), underscoring the severity of the public health hazard of slum housing.

B. Improved environmental health conditions in targeted buildings

Environmental health conditions improved substantially in a large majority of buildings included in the pilot project. This outcome is significantly different from previous organizing efforts and/or legal interventions that focused solely on civil violations which rarely resulted in critical repairs. By targeting many, and in some cases all, of a slumlord’s properties and applying a systematic, multi-pronged approach, the three targeted criminal slumlords were forced to significantly improve their properties.

Key elements of success were the expansive nature of the legal interventions; the threat (and in some cases reality) of incarceration; the significantly higher financial risks to the owner; and negative media exposure.

Of the 3,150 families in the pilot project properties, more than 90% experienced major improvements in living conditions.

These environmental health improvements have a direct, positive effect on tenants’ physical and mental health. Examples of specific improvements in environmental health in the targeted properties, as documented by tenants, organizers and promotoras, include:

• lead-based paint and/or lead-safe practices were adopted and enforced; • elimination or significant reduction in cockroach and vermin infestation; • fire code safety restored and regularly enforced;• adequate heating restored and maintained;• mold and mildew removed;• electrical hazards repaired and maintained;• elevators restored to proper working order; • substantial plumbing repairs made and ongoing maintenance enforced.

Additionally, there were financial benefits to about one-third of the tenants living in the targeted buildings. Through the combination of civil and criminal litigation, almost $15 million dollars were secured to benefit approximately 1,000 households in the targeted properties (individual awards varied widely based on household circumstances and position in the lawsuits). Although we did not attempt to document or measure the health impacts of the financial benefits, we know anecdotally that the financial awards improved mental health and provided tenants the resources to address physical and environmental health needs.

C. Improving Government Agency Practice and Alignment

One significant outcome was securing a commitment from the City Attorney’s office to dedicate resources to large, criminal slumlord activity and utilize innovative criminal charges including the possibility of using child endangerment statutes and case law to prosecute intransigent slumlords.

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The consequences were starkly different than in past cases. In fact, in two of the three pilot cases (Frank McHugh and Landmark Equity), the criminal prosecution forced the owners to agree to divest ownership of all properties in the City of Los Angeles. Additionally, Frank McHugh was sentenced to five years probation and one of the principles of Landmark Equity was incarcerated for several months. The combined result of these pilot cases can serve as an example of the consequences for landlords who engage in longstanding profit-making through disinvestment and criminal behavior and, hopefully, influence the behavior of all landlords in the City. In addition to changes in the City Attorney’s practices and consequences for large slumlords, this project and our collaborative have implemented and/or influenced other changes in policy and practices.

Other improvements and changes include:

• Pioneering a lower, evidence-based standard of lead poisoning, one based on prevention, that is now recognized and implemented throughout all Southside Collaborative clinics in South Los Angeles as well as by many public health nurses.

• Securing a commitment from the LA County Department of Public Health to assign public health nurses to work directly with physicians, clinic staff and community health promoters to engage in home visitation, in-home environmental assessments, and document direct medical evidence of the impact of the particular slum housing conditions on children and families living in slum housing units.

• Establishing a quarterly working group among housing and health organizations and the LA County Department of Public Health focused on improving health and housing outcomes in downtown Los Angeles that has resulted in information sharing and cross-training; improved bed bug interventions among County inspectors, tenants and landlords; increased and improved peer health promotion activities; and enhanced coordination across different divisions within Public Health.

• Building and deepening relationships with public interest law organizations (including Legal Aid Foundation of Los Angeles, Inner City Law Center, Neighborhood Legal Services and others) that resulted in crucial civil suits to legally supplement the criminal efforts and also strengthen the advocacy efforts to ensure the LA City Attorney’s office would focus on slumlord criminalization.

• Piloting a new means of utilizing medical experts in slum housing litigation that is informed and supported by the previous research and practice of this project team.

• Developing a comprehensive social medicine program at St. John’s Well Child and Family Center, in collaboration with the other project partners, which can be shared and promoted as a transformative working model for community health centers elsewhere. The field of social medicine seeks to transform the practice of medicine and apply a biosocial approach to address social and economic conditions that impact the health of patients and communities.

• Securing policy changes within the Community Redevelopment Agency of the City of Los Angeles to ensure that slum housing conditions and other tenant rights violations are prevented, monitored and enforced.

All of the practices, strategies and results described in above sections would simply not have been possible without the engagement and leadership of informed and active residents.

D. Increasing Power of Tenants to Change Policy and Practice

More than 2,500 tenants were engaged in at least one aspect of the project. Among those tenants, there were more than 250 core tenants who participated in health education and tenant rights sessions, filed complaints to government agencies and/or were plaintiffs in lawsuits, conducted outreach among their

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neighbors, organized building-wide meetings, collected documentation for and participated in legal efforts, gave public testimony, planned and engaged in direct action, and provided crucial information and leadership to move the goals of this project forward.

Grassroots leadership was both a necessary and highly effective component of this project, as well as our ongoing health and human rights efforts. On December 10, 2009 – International Human Rights Day – more than 200 people gathered around City Hall, calling on the Mayor and the City Council to prioritize one main issue: healthy and affordable housing as an inalienable right for all Angelinos. Relationships built during this project were expanded and coordinated with similar efforts across the City and County, resulting in an action that symbolized unity among cultures, races, and organizations that marched for housing rights and changes in housing and health policy.

Many community members active in this collaboration helped plan and lead this organizing effort and will continue to do so until the housing and health rights of everyone in Los Angeles are guaranteed.

CONCLUSIONS AND NEXT STEPS

There are three key areas in which the Slumlord Criminalization and Health Impacts project can help inform future policy and practice:

1. Health and Human Rights Framework and PracticeWhile Los Angeles has a strong and rich history of resilience, of social justice movements and innovative community organizing, fundamental human rights developed under the Universal Declaration of Human Rights have yet to be realized. The right to employment and safety, the right to education, the right to housing and food security, and the right to health are all basic human rights outlined in the Declaration which have been denied to most residents of Downtown and South Los Angeles, as well as most low-income communities and communities of color across the city and the country.

The human rights framework has largely been ignored in the United States, and this has had dramatic repercussions for poor and underserved communities struggling against a myriad of social and economic conditions which have severely and negatively affected their health status. Our collective organizing, advocacy and direct service strategies must move toward a human rights approach in order to fully address the overarching and interrelated health issues facing our communities. Engaging patients in this process is critical. On December 10, 2009, International Human Rights Day, more than 300 medical patients, tenants and community residents convened at Martin Luther King Hospital and established the South Los Angeles Declaration of Health and Human Rights. This document encapsulated the health and human rights framework and engaged a plan to address the health conditions the community faces as well as the social determinants.

The Healthy Neighborhoods, Same Neighbors Collaborative, as well as dozens of our community partners and hundreds of residents, are committed to creating programs and projects that promote interdependent, interrelated human rights approaches. We believe this project, as well as several other community-based efforts, provide a model for government officials, as well. Just as interdisciplinary projects such as ours are necessary to address health and housing conditions simultaneously, intergovernmental efforts are necessary to solve this problem on a larger scale. Public resources simply must build upon, support and supplement effective community-based strategies. It is only when tenants are organized, research is assembled on criminal patterns and practices in

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multiple buildings, lawyers are engaged, and public processes are responsibly engaged at a high level, that the systematic and intentional slum practices of an owner are even noticed. These are unusual cases that require a high level of investment by community-level organizations, such as the ones involved in this project in order to fill in the gaps and link a disjointed public system.

Our goal is to transcend these unusual cases, and instead set a new standard for the City’s systems and practices.

2. South Los Angeles Integrated Health Care SystemBased on the multiple successes of our collaborative in improving individual and environmental health through the combination of direct health care services, health promotion/promotoras’ in-home education, and community organizing, this interdisciplinary model should be considered as part of any health care delivery system.

As Los Angeles County moves forward in developing and implementing the South LA Integrated Health Care System, it must include coordinated interventions that address immediate health needs as well as the multiple social determinants of health, including housing conditions.

With the reopening of Martin Luther King, Jr. Hospital as the centerpiece of this integrated delivery network, coordinated preventive strategies that engage the root causes of disease prevalence in South Los Angeles must be engaged. This will directly create the biosocial environment necessary to directly improve health outcomes among South L.A. residents.

We believe that our collaborative is uniquely qualified to inform this process.

3. Community Leadership and PowerEngagement of those most impacted by human rights violations is a necessary component of implementing the human rights framework. Additionally, developing community leadership is essential to building the power needed to influence systems change.

Through the work of this collaborative, we have transformed patients into active change-makers, expanded the role of tenant leaders and community health promoters into human rights defenders, broken down barriers between traditional housing and health work, and have built the foundations for a broad base of residents working together in solidarity across race, geography and issue areas.

This collaborative has redefined what it means to be a health care provider as well as what it means to be a “patient”. For us a patient is not just a consumer or recipient of health care services, but rather a vital community member with the capacity to impact the living and working conditions that affect their health. Our job in health care is to work with patients in this framework and build capacity--to serve, to organize, to partner, to advocate. This approach also transforms the ability of health care providers to acknowledge and integrate experiences of patients as workers and tenants.

Obtaining the power needed to heal our communities rests in our ability to identify and build local leaders committed to a common vision of community health. Leadership development, including developing a deeper analysis of the failures of multiple systems to provide basic human rights, provides the impetus to make change. This project and similar efforts continue to demonstrate both the need for and effectiveness of low-income residents who are deeply engaged in creating and implementing true sustainable solutions to health and housing needs.

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“After we won the lawsuit, not only did our housing conditions improve, but I felt better mentally. I could finally relax. I was also able to get some equipment to help my chronic back pain and get in-home care.

We didn’t just fight back - we achieved dignity, respect, and a healthy environment.” Quote of resident involved in the Slumlord Criminalization and Health Impact Project as a plaintiff

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Appendix A

Research on the Link Between Substandard Housing and HealthHealthy Neighborhoods, Same Neighbors CollaborativeNote: This list is not exhaustive

Symptoms of Wheeze and Persistent Cough in the First Year of Life: Associations with Indoor Allergens, Air Contaminants, and Maternal History of Asthma. August 1, 2003, American Journal of Epidemiology. Kathleen Belanger, William Beckett, Elizabeth Triche, et al.

Association of Housing Disrepair Indicators with Cockroach and Rodent Infestations in a Cohort of Pregnant Latina Women and Their Children. July 2005, Environmental Health Perspectives. Asa Bradman, Jonathan Chevrier, Ira Tager, et al.

National Prevlance and Exposure Risk for Cockroach Allergen in US Households. November 2005, Environmental Health PerspectivesRichard D. Cohn, Samuel J. Arbes, Jr., Renee Jamamillo, Laura H. Reid, and Darryl C. Zeldin

Home and Allergic Characteristics of Children with Asthma in Seven U.S. Urban Communities and Design of an Environmental Intervention: The Inner-City Asthma Study September 2002, Environmental Health Perspectives. Ellen F. Crain, Michelle Walter, George T. O’Connor, et al.

Exposure to multiple indoor allergens in US homes and relationship to asthma. 2008. Journal of Allergy and Clinical Immunology. Salo PM., Arbes SJ., et al.

Asthma in Children: Environmental Factors. June 1994, British Medical Journal. P. Cullinan and A.J. Taylor

The Environment and Asthma in U.S. Inner Cities. June 1999, Environmental HealthPerspectives. Peyton A. Eggleston, Timothy J. Buckley, Patrick N. Breysse, et al.

How Environmental Exposures Influence the Development and Exacerbation of Asthma. July 2003, Pediatrics. Ruth A. Etzel

The Relationship Between In-Home Water Service and the Risk of Respiratory Tract, Skin, and Gastrointestinal Tract Infections Among Rural Alaska Natives. Arctic Investigations Program, Centers for Disease Control and Prevention (CDC). 2008, American Journal of Public Health.. Thomas W. Hennessy, Troy Ritter, Robert C. Holman, Dana L. Bruden, Krista L. Yorita, Lisa Bulkow, James E Cheek, Rosalyn J. Singleton, Jeff Smith

Invasive pneumococcal disease in Alaskan children: The role of water supply and the pneumococcal conjugate vaccine (PCV). Abstract 208063. American Public Health Association Conference 2009. Arctic Investigations Program, Centers for Disease Control and Prevention (CDC). Jay Wenger. Available at http://apha.confex.com/apha/137am/webprogram/Paper208063.html.

Housing Quality and Children’s Socioemotional Health. February 2003. Robert Gifford, Canadian Mortgage and Housing Corporation.

Clearing the Air: Asthma and Indoor Air Exposures. 2000, National Academy Press. Institute of Medicine, Committee on the Assessment of Asthma and Indoor Air.

Indoor Allergens: Assessing and Controlling Adverse Health Effects. 1993, National Academy Press. Institute of Medicine, Committee on the Health Effects of Indoor Allergens. Andrew M. Pope, Roy Patterson, and Harriet Burge, Editors.

Residential Exposures Associated with Asthma in US Children. March 2001, Pediatrics. Bruce Lanphear, C. Andrew Aligne, Peggy Auinger, et al.

Is There a Dose-Response Relationship between Exposure to Indoor Allergens and Symptoms of Asthma? October 1995, Journal of Allergy and Clinical Immunology. Thomas A. E. Platts-Mills, Richard B. Sporik, Lisa M. Wheatly, and Peter W. Heymann.

The Role of Intervention in Established Allergy: Avoidance of Indoor Allergens in the Treatment of Chronic Allergic Disease. November 2000, Journal of Allergy and Clinical Immunology. Thomas A. E. Platts-Mills, John W. Vaughan, Melody C. Carter, and Judith A. Woodfolk.

Deteriorated Housing Contributes to High Cockroach Allergen Levels in Inner-City Households . April 2002, Environmental Health Perspectives. Virginia A. Rauh, Ginger L. Chew, Robin S. Garfinkel.

The Role of Cockroach Allergy and Exposure to Cockroach Allergen in Causing Morbidity among Inner-City Children with Asthma. May 1997, New England Journal of Medicine. David L. Rosenstreich, Peyton Eggleston, Meyer Kattan, et al.

Sensitisation to Airborne Moulds and Severity of Asthma: Cross Sectional Study from European Community Respiratory Health Survey. August 2002, British Medical Journal. Mahmoud Zureik, Catherine Neukirch, Bénédicte Leynaert, et al.

Toxic Effects of Indoor Molds. April 1998, Pediatrics. American Academy of Pediatrics Committee on Environmental Health.

Home is Where the Harm Is: Inadequate Housing as a Public Health Crisis. May 2002, American Journal of Public Health. Samiya A. Bashir.

Damp Indoor Spaces and Health. May 2004, National Academies Press. Institute of Medicine of the National Academies.

Public health significance of urban pests. 2008, Xavier Bonnefoy, Helge Kampen and Kevin Sweeney. . Available at http://www.euro.who.int/InformationSources/Publications/Catalogue/200806179

Housing and Health: Time Again for Public Action. May 2002, American Journal of Public Health . James Krieger and Donna L. Higgins. Available at www.ajph.org/cgi/reprint/92/5/758.pdf

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Housing and Health – Current Issues and Implications for Research and Programs, March 2000, Journal of Urban Health, Thomas D. Matte and David E. Jacobs

How Substandard Housing Affects Children’s Health, October 2000, Contemporary Pediatrics. Megan Sandel and Jean Zotter

There’s No Place Like Home: How America’s Housing Crisis Threatens Our Children. March 1999, Doc4Kids Project. Megan Sandel, Joshua Sharfstein, and Randy Shaw

Housing and Public Health. 2004, Annual Review of Public Health. Mary Shaw

The Relationship between Housing and Health: Children at Risk, 2004, Environmental Health Perspectives, 12, (no. 15) (2004): 1583-88, Breysse, Patrick, and et. al.

Leading Our Nation to Healthier Homes: The Healthy Homes Strategic Plan. 2009, Available at: www.hud.gov/offices/lead/library/hhi/hh_strategic_plan.pdf. United States Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control.

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Sponsored by the Healthy Neighborhoods, Same Neighbors Collaborative:

Strategic Actions for a Just Economy (SAJE), St. John’s Well Child and Family Centers, Los Angeles Community Action Network,

Esperanza Community Housing Corporation.

Support for this community health research and intervention project has been provided by:

The California EndowmentThe California Wellness Foundation

EveryChild FoundationMarguerite Casey Foundation

Liberty Hill FoundationSolidago Foundation